Healthcare Provider Details

I. General information

NPI: 1134876451
Provider Name (Legal Business Name): NATHANIEL JOHN HEARON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3314 N COLE RD
BOISE ID
83704-4403
US

IV. Provider business mailing address

3314 N COLE RD
BOISE ID
83704-4403
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-9930
  • Fax:
Mailing address:
  • Phone: 208-377-9930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-2240
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: